EMPLOYMENT APPLICATION We consider applicants for all positions without regard to race, religion, creed, gender, age, disability, marital or veteran status, sexual orientation or any other legally protected status. Position Applied For: Date: How did you learn about us? Advertisement Relative Inquiry Employment Agency Friend Other (please specify): APPLICANT INFORMATION (Please Print) Last Name: First Name: MI: Street Address: Apt/Unit # City: State: Zip: Phone #: Alternate Phone #: E-mail Address: Best time to contact you (AM/PM): Date available to work: Choose work availability and indicate date and hours available: Full Time: Part Time: Temporary: Desired salary range: If you are under 18 years of age, can you provide required proof of your eligibility to work? Have you ever filed an application with us before? If yes, please list date: Have you ever been employed with us? If yes, please list date: Do any of your friends or relatives work or volunteer here? Are you currently employed? If yes, may we contact your present employer for references? Are you prevented from lawfully becoming employed in this Country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment. Rev. 9/28/2016 Employment Application 1
EDUCATION Name and Address of School Elementary: Course of Study Years Completed Diploma/Degree High School: Undergraduate: Graduate: Other (Please Specify): Please describe any specialized training, apprenticeship, skills and extra-curricular activities: Please describe any job-related training received in the United States military: Rev. 9/28/2016 Employment Application 2
EMPLOYMENT EXPERIENCE Please start with your present or most recent job. Include any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities or any other legally protected status. EMPLOYER NAME: Position/Job Employed From: Employed To: Starting Pay: $ Final Pay: $ Supervisor Name: Work Performed: Supervisor Position: Reason for Leaving: EMPLOYER NAME: Position/Job Employed From: Employed To: Starting Pay: $ Final Pay: $ Supervisor Name: Supervisor Position: Work Performed: Reason for Leaving: EMPLOYER NAME: Position/Job Employed From: Employed To: Starting Pay: $ Final Pay: $ Supervisor Name: Supervisor Position: Work Performed: Reason for Leaving: Rev. 9/28/2016 Employment Application 3
Please list professional, trade, business or civic activities and offices held. You may exclude membership that would disclose gender, race, religion, national origin, age, ancestry, disability or any other legally protected status: ADDITIONAL INFORMATION Other qualifications: Summarize special job-related skills and qualifications acquired from employment or other experience: COMPUTER SKILLS Please Check: Email Internet Word Excel Database Other Software Proficiency: State any additional information you feel may be helpful to us in considering your application: Reasonable Accommodation Notice Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. ---------------------------------- Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a satisfactory manner, with or without a reasonable accommodation, the essential functions of the job for which you have applied? Yes No Rev. 9/28/2016 Employment Application 4
PROFESSIONAL REFERENCES Reference 1 Name: Reference 2 Name: Reference 3 Name: Reference 4 Name: Rev. 9/28/2016 Employment Application 5
APPLICANT S STATEMENT I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed twelve months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether applications are being accepted at that time. I hereby understand and acknowledge that, unless defined by applicable law, any employment relationship with this organization is of an at will nature, which means that the Employee may resign at any time and ARISE may discharge Employee at any time with or without cause. It is further understood that this at will employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of ARISE. I understand that if I want to be considered for a position as a personal care assistant, individuals and/or their designees who want to hire personal care assistants may review my application. If I am applying to work or volunteer with individuals with whom I may have regular and substantial unsupervised and unrestricted contact, I understand that I must sign a Criminal History Record Check consent form, present photo identification, and submit to being fingerprinted. If I may work in a similar capacity with clients under age 18, or with anyone receiving services funded by New York State under the jurisdiction of the Justice Center, I understand that I must complete a State Central Register Database Check form which will be submitted to the New York State Office of Children and Family Services to determine whether I have ever been the subject of an indicated case of child abuse or maltreatment, and the outcome of that investigation. A background check conforming to Mental Hygiene Law, Staff Exclusion List and reference checks may also be conducted. Because ARISE provides services to clients and subsequently bills Medicaid for services provided in an aggregate amount that exceeds $50,000 annually, each person with a conditional offer of employment, as well as each employee and intern under supervision by a licensed clinician, will be subject to periodic exclusion checks. ARISE cannot employ or engage as a volunteer any person who is excluded, terminated, or otherwise disqualified from participation in Medicaid or Medicare. An exclusion check is a search of the following databases to determine if the individual s name appears on any list: NYS Office of the Medicaid Inspector General's List of Excluded and Terminated Providers (http://www.omig.state.ny.us/fraud/medicaid-terminations-and-exclusions) Office of the Inspector General List of Excluded Individuals and Entities (http://exclusions.oig.hhs.gov/) System for Award Management - This is the Official US Government system that consolidated the Excluded Parties List System list with other federal procurement systems (www.sam.gov) In the event of employment or volunteer service, I understand that false or misleading information given in my application, resume and / or interview(s) may result in discharge. I also understand that I am required to abide by ARISE s rules, regulations, policies and procedures. Have you ever been the subject of an indicated report of child abuse, neglect or maltreatment? Yes No If yes, was it indicated or unfounded Indicated Unfounded If yes, was your record expunged? Yes No Signature Date Print Name Social Security Number Rev. 9/28/2016 Employment Application 6
SELF-IDENTIFICATION FORM Federal laws and regulations require us to report on our workforce by race, gender, and veteran status and to offer the opportunity for self-identification as to disabilities. Please assist us by completing this form. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. Data which you provide shall be kept strictly confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled individuals and/or disabled veterans; (ii) first aid and safety personnel may be informed, to the extent appropriate, if the condition might require emergency treatment; and (iii) governmental officials reviewing the Company's compliance status shall be informed. Last Name First Name MI: Social Security Number (Optional) Gender: Male Female Race/Ethnicity: (Please check one) White (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Hispanic or Latino Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) American Indian or Alaska Native (Not Hispanic or Latino) Two or More Races (Not Hispanic or Latino Veteran Status: (Check all that apply) I am a disabled veteran. t I am a recently separated veteran. t Date of discharge (MM/DD/YYYY) I served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized. I participated in a United States military operation for which an Armed Forces Service Medal was awarded, while serving on active duty in the Armed Forces, pursuant to Executive Order No. 12985 (61 Fed. Reg. 1209). Disability I am an individual with a disability.* I have received the form and decline to provide the requested information. * Categories consistent with 41 C.F.R. 60-300 & Form VETS-I OOA t If you need a definition of these terms, please see below. SELF-IDENTIFICATION FORM DEFINITIONS The term "Disabled Veteran" means: o A veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Department of Veterans Affairs for a disability; or o A person who was discharged or released from active duty because of a service-connected disability. The term "Recently Separated Veteran" applies to any veteran during the three -year period beginning on the date of discharge or release from active duty. An "individual with a disability" means any person who (i) has a physical or mental impairment which substantially limits one or more of such person's major life activities; (ii) has a record of such impairment; or (iii) is regarded as having such impairment. Rev. 9/28/2016 Employment Application 7